Substantial Falls Increase Concern About Falling: a 12-Month Longitudinal Cohort Study Running title: Understanding the Development of Concerns About Falling in Older Adults

Background: Concern about falling (CaF) is common in older adults and predict falls, disability and loss of independence. However, it is unclear whether CaF is relatively stable or whether new falls contribute to increased CaF over time. The purpose is to examine whether experiencing falls predicts CaF, independent of other physical, cognitive, and psychological characteristics. Methods: We analysed data from 489 community-living older adults aged 70-90 years. CaF was measured using the Falls Efficacy Scale-International (FES-I) at baseline and 12-months. Falls and injuries were prospectively monitored. Baseline predictors included physical and cognitive performance, mood, personality traits, and demographic variables. Single predictor variable and multivariable linear regression analyses examined predictors of CaF at follow-up, adjusting for baseline CaF. Results: Many physical, cognitive and mood variables were associated with CaF in the adjusted single predictor analyses. Experiencing one injurious fall or multiple falls during follow-up was a significant predictor of CaF (β = 1.55, p = 0.007). Other independent predictors included baseline CaF (β = 0.70, p < 0.001), slower Timed Up and Go performance (β = 0.63, p < 0.001), lower conscientiousness (β = –0.11, p = 0.016), and older age (β = 0.17, p = 0.01). Conclusion: Our findings suggest that while CaF exhibits some stability, it can be significantly elevated following injurious or multiple falls. Targeted assessment and support following injurious or recurrent falls may help prevent persistent concern, particularly in people with reduced mobility or lower psychological resilience. These findings highlight the importance of post-fall review in clinical care.